CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 5

Exercise 1

Compare Maigne’s syndrome and osteoporotic compression fracture of at

the thoracolumbar junction
Answer:
osteoporotic fracture at thoraco-lumbar junction collapses the anterior
margin to less then half the height of the posterior margin , more then 20
degrees of wedging may indicate a unstable fracture.
*Compression fractures are due to weakness in bone
*35% in women over 40 years of age
*30% long term corticosteroid use
*8% hyoerthroidism
*2% malignancy
flexion movements /exercised are to be avoided
Evaluation:
*often sharp kyphotic angle at area of fracture
*pain on percussion & deep pressure over segment involved
*radiographic diagnosis essential
(reference Tomas Souza pg100)

Maigne’s Syndrome :
*manipulable lesion affecting thoracolumbar junction with secondary reflex
(not radicular) invoves gluneal nervers giving rise to referred pain in lower
back
*unexplained activation of primary division of ramus of spinal nerve 9dorsal
ramus)
*neuropathic skin changes (thickening of skin, hair loss, swollen puffy
appearance)
*hypersensitivity of skin over iliac crest (skin roll test)
*manipulable lesion on palpation
*radiographic evidence in effective
*unilateral or bilateral pain over iliac crest possible groin pain
*no radiating pain
(refer lecture notes Wk5)

A. What do these two conditions have in common?

Ans: pain over the segment (palpation)
B. What are the features of each
Ans: listed above
 C. How would you differentiate them?
Ans: highlighted above

Exercise 2

Differential Diagnosis of LBP with Radiculopathy

Disc Herniation Spinal Stenosis Cauda Equina

Age 30-55 >60 40-60

History Acute or recurrent Insidious onset of Insidious onset LBP with

episodes chronic progressive or W/O saddle anaesthesia
LBP more recent onset , bowel/bladder functions
of LE symptoms ,acute or chronic LBP
(*assume LE means
lower extremity)
Pain pattern Pain and or LE symptoms Usually radiculopathy
numbness radiating increases with lumbar bilateral-pain , tingling
to unilateral LE extension and relieved ,numbness, increased with
below the knee by flexion flexion
,usually increased
with flexion
Neuro Exam Sensory and/or Sensory and motor Bilateral sensory and
motor changes, changes or/motor changes,
diminished absent diminished absent
DTR unilateral reflexes, sensory and
motor changes S3-4
ROM Guarded/Limited Pain and limited Garded limited
extension

Other Tests SLR Treadmill test SLR

Exercise 3

This exercise will require some investigation on your part

You are required to ask for any additional information in the Q&A moodle chat.
However, when you ask for more information you must identify specifically what
information you want and why (ie. What differential diagnoses are you considering
and what will the information provide to help you)

Case History

Mark, 12yom, presented to your office with his Mum. Mark’s mother explained that
he has been complaining of back pain for the past few weeks, maybe longer. She is
unaware of any particular injury that started this and Mark doesn’t recall any
specific injury either. She explains he is a typical boy, plays soccer and rides at the
mountain bike park a few times a week. She would consider him relatively active but
he does like his ‘devices’ when he’s allowed. Mark says the pain is ‘pretty sore’
sometimes, he guesses it is about 5/10 and when asked to indicate where it is he runs
his hand across the region of the thoracolumbar spine.
Further Questions :
Age ?
Ask mark Exactly when or what that he was doing at onsett
the LOD-CT-RRAPPA system of history taking
Radiating pain ?
localized pain ? referral ?
previous episodes ?
Aggravating factors ?

Exercise 4

Explain Peripheralisation and Centralisation as they apply to the clinical presentation

and treatment of LBP with radiculopathy

Answer:

Centralisations :
Centralizations implies moving towards or is centred in the lumbar spine .
Peripheralization implies pain is being referred or is moving into the limb .
determining the doctor must use differential diagnostic skills
and methodically follow the LOD-CT-RRAPPA analogy of complete history taking
and aggravating and relieving factors and so on.
Some more bullet points :
* only 5 % of LBP is disc related (pain traveling below the knee is a key indicator)
*Localized pain with referral trigger points (mechanical) must be differentiated
*some disc bulges may result in only back or buttock pain .
*facet joints pain ? injury or degeneration pain ?
*lumbar and sacroiliac pain referrers to posterior leg and sometimes to lateral aspect
of leg .
(Reference: Magee pg 476-477)
Exercise 5

Besides those examples provided in the lecture, what questions might you ask to
determine if a patient has signs and symptoms associated with Cauda Equina
Syndrome?

Questions :
*Urinary retension ?
*bowel and or bladder dysfunction?
*Lower back pain ? (bi lateral ?)
*Acute or chronic radiating pain?
*unilateral or bilateral pain lower extremity motor and/or sensory abnormality
*saddle (perineal) anaesthesia
*Limited ROM
*antalgic gait /posture
(Reference : Orthopaedic Conditions Viziniak pg116-117)
also methodically follow the LOD-CT-RRAPPA
Location
Onsett
Duration
Course frequency
Type of pain
radiating pain ?|Releiving factors ?
Aggravating factors ?
previous episodes?
previous treatment ?
Associated signs and symptoms ?